Medicine has made profound advances in treating many diseases, but in its great strength lies its debilitating weakness.
Organizing for Professional Work
To understand this, consider how professional work tends to be organized. Much of it is rather standardized, carried out by highly-trained people with a good deal of individual autonomy—at least from their colleagues, if not from the professional associations that set their standards. Just as the musicians of a symphony orchestra play in harmony while each plays to the notes written for his or her instrument, so too can a surgeon and anesthetist spend hours in an operating room without exchanging a single word. By virtue of their training, each knows exactly what to expect of the other.
Accordingly, much of modern medicine does not solve problems in an open-ended way so much as categorize patients’ conditions in a restricted way. Each is slotted into an established category of disease—a process known as diagnosis—to which an established, ideally evidence-based treatment—referred to as a set of protocols—can be applied.
This standardization is not, however, absolute: it takes the form of tailored customization. (See our article Customizing Customization.) The predetermined standards—those protocols—are tailored to the condition in question. The patient presents with a pain in the chest; the diagnosis indicates a blocked artery; a particular stent is installed in a particular place; and an administrative box is ticked so that a standard payment can be made.
The great strength of modern medicine lies in the fits that work. The patient enters the hospital with a diseased heart and leaves soon after with a repaired one. But where the fit fails can be found modern medicine’s debilitating weakness. Fits fail, more often than generally realized, beyond the categories, across the categories, and beneath the categories.
Beyond the categories lie those illnesses that fit into no predetermined category of disease. The patient may not be treated at all—indeed, sometimes dismissed as a hypochondriac—or forced into an inadequate, if convenient, category. Think about IBS (Irritable Bowel Syndrome), a label for ignorance, or some auto-immune conditions.
Across the categories fall those patients with multiple conditions that fit several disease categories concurrently. If these can be treated sequentially, the professional model of organizing is preserved. He or she is sent from one specialist to another. But where the conditions interact in more complex ways, as in many geriatric cases, more open-ended, collaborative problem-solving can be required. (The chief of geriatrics in a Montreal hospital, big on teamwork, used to say that a physiotherapist was their best diagnostician.) While geriatric departments may be encouraged to engage in such collaboration, much of the rest of medicine, where multiple diseases implicate different departments, each grinding in its own mill, does not. How often do we hear from frustrated patients: “Why can’t they just speak with each other, instead of passing around these little notes while I am being asked to describe my condition again and again?”
Beneath the categories lies a misfit that is no less common, or significant, than the other two. The fit is correct, but insufficient for effective treatment. Here medicine has to get past the “patient”, to the person.
Dr. Atul Gawande, in a New Yorker article entitled “The Bell Curve” (6 December 2004), reported on his observation of a renowned cystic fibrosis physician. He wrote the protocols that others used, yet had much better results. Meeting a young woman, and seeing a reduced measure of lung-function, he asked if she was taking her treatments. She said that she was. But he probed further, to discover that she had a new boyfriend and a new job that were getting in the way of taking those treatments. Together they figured out how she could alter her schedule.
Here, then, lay the good doctor’s secret: he treated the person and not just the patient, by delving beneath the medical context, to her personal situation.
Management and Medicine Alike
Of course, too much contemporary administration hardly encourages this kind of probing. If the administration of that doctor’s hospital was managing in the modern way, it may have questioned why he was spending so much time with this one patient. True she might live longer, but how to measure that in a budgeting system focussed on current expenditures?
Before any physician jumps on this point with great glee, he or she would do well to recognize that the management weakness here is not fundamentally different from that of medicine. Both suffer from an excessive tendency to categorize, commodify, and calculate—indeed, much like the rest of modern society. (See my TWOG on pat and playful puzzles.) Are managers who claim that “If you can’t measure it, you can’t manage it” any more sensible than physicians who claim that “If it’s not evidence-based, it’s not proper medicine”? Subscribing to either canon would close down both management and medicine.
Evidence-guided medicine is fine, as is evidence-guided management. That good doctor used the evidence presented to him. But he probed beneath it, to that woman’s experience. Within and across the categories called medicine and management, physicians and administrators alike would do well to get past their common debilitating weakness, to engage collaboratively for better health care.
© Henry Mintzberg 2018, drawing from my book, Managing the Myths of Health Care